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U18 Urology
Stone Disease
Toronto Notes 2019
Key Points in Stone Hx
• Diet (especially FLUID INTAKE)
• Predisposing medical conditions
• Predisposing medications
• Previous episodes/investigations/
treatments
• Family Hx (1st degree relative)
The four narrowest passage points for upper tract stones are:
• UPJ
• Pelvic brim
• Under vas deferens/broad ligament • UVJ
Stone Disease
Epidemiology
• prevalence:~8%andincreasing
• M:F=2:1
• peakincidence30-50yrofage
• recurrencerate:10%at1yr,50%at5yr,60-80%lifetime
Risk Factors
• hereditary:RTA,Glucose-6-phosphatedehydrogenasedeficiency,cystinuria,xanthinuria,oxaluria,etc. • lifestyle:minimalfluidintake;excessvitaminC,oxalate,purines,calcium
• medications:loopdiuretics(furosemide,bumetanide),acetazolamide,topiramate,zonisamide,
indinavir, acyclovir, sulfadiazine, triamterene
• medical conditions: UTI (with urea-splitting organisms: Proteus, Pseudomonas, Providencia, Klebsiella,
Mycoplasma, Serratia, S. aureus), myeloproliferative disorders, IBD, gout, DM, hypercalcemia disorders
(hyperparathyroidism, tumour lysis syndrome, sarcoidosis, histoplasmosis), obesity (BMI >30) • bladderstones:bladderoutletobstruction,catheters,neurologicdisease,DM(requiresdifferent
management)
Clinical Features
• ClinicalFeatures
• urinary obstruction → upstream distention → pain
■ flank pain from renal capsular distention (non-colicky)
■ severe waxing and waning pain radiating from flank to groin, testis, or tip of penis from distended
collecting system or ureter (ureteral colic)
• writhing,persistentdiscomfort,nausea,vomiting,hematuria(90%microscopic),diaphoresis,
tachycardia, tachypnea
• occasionallysymptomsoftrigonalirritation(frequency,urgency),ifthestoneisinthelowerureter • bladderstonesresultin:storageandvoidingLUTS,terminalhematuria,suprapubicpain
• iffever,ruleoutconcurrentpyelonephritisand/orobstruction
• canalsopresentincidentally,withoutanypainorsymptoms
Table 11. Differential Diagnosis of Renal Colic
GU
Pyelonephritis
Ureteral obstruction from other cause: UPJ obstruction, clot colic secondary to gross hematuria, sloughed papillae Gynecological: ectopic pregnancy, torsion/ rupture of ovarian cyst, PID
Location of Stones
Abdominal
AAA
Bowel ischemia
Pancreatitis
Other acute abdominal crisis (appendicitis, cholecystitis, diverticulitis)
Neurological
Radiculitis (L1): herpes zoster, nerve root compression
Radiopaque
KUB Calcium Struvite Cystine
CT Calcium Struvite Cystine
Uric acid
Radiolucent
Uric acid Indinavir Atazanavir
Indinavir Atazanavir
• calyx:maycauseflankdiscomfort,persistentinfection,persistenthematuria,orremainasymptomatic • pelvis:tendtocauseobstructionatUPJ,maycausepersistentinfection
• ureter:<5mmdiameterwillpassspontaneouslyin75%ofpatients
Stone Pathogenesis
• supersaturationofstoneconstituents(atappropriatetemperatureandpH) • stasis,lowflow,andlowvolumeofurine(dehydration)
• crystalformationandstonenidus
• lossofinhibitoryfactors
■ citrate (forms soluble complex with calcium)
■ magnesium (forms soluble complex with oxalate) ■ pyrophosphate
■ Tamm-Horsfall glycoprotein